An Evaluation of a Value-Based Health Plan Design at Group Health

David Grossman, MD, MPH

Group Health Research Institute

Seattle, Washington

Disclosures and Funding

PI is employee and shareholder, Group Health Permanente medical group

Funding from AHRQ (R01 HS018913-01) and Group Health Cooperative

Improving Value of US Healthcare Expenditures

Increased purchaser focus on:

• Improving value of expenditures

• Reducing waste

• Improving health outcomes for beneficiaries

• Preventing chronic illness and complications

Two main levers

• Health plan design

• Delivery system design

Cost-Sharing and HealthImpact of larger cost-shares on chronic disease self-management

Chronic disease the major driver in health care costs

Re-consideration of indiscriminate cost-sharing

• Consumer holds the early short term risk

• Purchaser/health plan holds the longer term risk

Value-based Cost-Sharing

First iterations:

• Preventive service coverage

• Tiered pharmacy benefits

Generics

Brand-name

Non-preferred and non-formulary

Most recent efforts focused on pharmacy cost-sharing: reducing cost-shares

• Pitney Bowes

• University of Michigan employees

Science of Value-Based Design

Large body of evidence on impact of increased cost-shares

• Tends to be focused on discrete services

Much smaller literature on impact of reducing cost shares

Even smaller literature on impact of cost-sharing on health outcomes and productivity

Tiny literature using control group with multiple outcomes

Worksite WellnessAnother approach to reducing costs and improving health

• Focus on lifestyle change

Incenting health behavior

Healthy work environments

Change of work culture

• Outcomes of interest

Health status and utilization

Absenteeism and presenteeism

Productivity

• 77% of large employers offer these services

• Health risk assessments are entry portal for engagement

Group Health’s Total Health Plan for Employees

Employer Aims

• Improve productivity through

Better health of staff

Decreased absences

Improved on-the-job productivity

• Decrease health expenditure trend rate

Mechanism

• Incent healthy behaviors and improved chronic disease control through monetary incentives and value-based health benefit pricing

• Reinforce culture of self-awareness, accountability and reporting of health and health behaviors through monetary incentives and culture change

Specific AimsTo assess the impact of the new value-based insurance design on:

PRIMARY: changes over time in employee self-reported:

• health status

• absenteeism due to illness and disability

• presenteeism (i.e. lost productivity time at the workplace)

SECONDARY:

• clinical quality scores for chronic illness care and preventive screenings,

• lifestyle behavioral risk factors,

• employee satisfaction with health benefits,

• health services utilization by employees, and

• employer-paid health costs for the employee population.

Invitation to complete HRA

Feedback report with health risksIdentified

· Improved health status· Decreased absenteeism· Improved workplace productivity

Lifestyle & behavioral risk factors

Improved management of chronic illnessChronic

Illness self-management

needs

TotalHealth Program

Design and Incentives

Reduction in lifestyle and

behavioral risk factors

Figure 1: Conceptual Framework

Opt-out*

· Reduced unexpected healthcare utilization

· Decreased employer health costs

Total Health Design OverviewValue-based copayments

Preventive services (already 1st dollar): no change

Chronic disease cost-sharing decreased for

Selected Visits

Pharmacy

Worksite wellness and health promotion activities

• Engagement tied to premium stabilization for 3 years

Health risk assessment annually, AND

Achievement of point threshold

Points aimed at both healthy and chronically ill staff

Visit Cost-Sharing

Waiver of co-pay for 2 visits/year for chronic care

• Coronary Artery Disease

• Diabetes

• Hypertension

• Congestive Heart Failure

• Asthma

• Mental Health (first ten visits)

Waiver of copay for chemical dependency visits and lactation service visits

Pharmacy Co-payments

Copayments reduced to zero for:

• generic, mail dispensed meds for same diseases plus depression

Copayment reduced for brand name drugs for same diseases

Devices

Wavier of cost-sharing for:

• Home BP monitors

• Diabetic glucose monitors

• Spaces for inhaled asthma meds

Obesity Management Programs

50% discount for enrollment

100% coverage (50% rebate) for diabetics that lose five percent of body weight

Cost-Shares Increased

Outpatient surgery

High cost imaging procedures

• CT, MRI, PET

Total Health Website

Total Health Evaluation Design

Study Design

• Quasi-experimental 2 group before/after design

• Repeated measures

• Control group: Kaiser Permanente Colorado employees

OutcomesPrimary

• Health status change: Survey

• Absenteeism due to illness: Survey +HR data

• Productivity at work: Survey

Secondary

• Care Quality scores

Chronic illness: HEDIS scores

Preventive services HEDIS scores

• Lifestyle behavioral risk factors Survey

E.g. smoking, activity

• Employee satisfaction Survey

• Costs and service utilization Claims data

Survey ToolSurvey invitation to employees

• Web survey tool

Paper survey on request

Domains: Instrument

Functional Status: (SF-12)

Workplace productivity: Work Health Interview

Health Risk Behaviors BRFSS, other

» Tobacco

» Alcohol

» BMI

» Physical Activity

» Satisfaction w/ plan

Administrative Data

Health utilization/cost/quality

• Group Health Research Institute data warehouse

Claims

Pharmacy

EMR data

Employee characteristics

• Human Resources administrative data

Data Collection

Sample of 5000 employees invited to take e-survey tool

• Active opt-out

• Implied consent with survey completion

• Separate permissions to link claims and HR data

• 3 follow-up emails

• No telephone follow-up

Statistical Power

Mean/

Percent SD

Minimum detectable difference

Presenteeism (hours) 5.2 7.5 0.57 Absenteeism (hours) 11.0 14.0 1.06 Lost productive time (hours) 15.3 14.4 1.09 Self-rated health (excellent/very good) 57% -- 3.8%

Total Health – participation• >80% of all staff and spouses/domestic partners on the TH medical plan have taken the HRA

•73% are earning points on the wellness website

Progress to Date

Baseline survey completed early 2010

• Group Health: 70% response rate

• KPCO: 60% response rate

Permissions to link survey data

• Approximately 60-64% agree to linkage with HR and/or medical data

Challenges and Strengths

Privacy issues/concerns

• Employer is also provider of care

• Key engagement of organized labor units

Validity of self-reported data

Study design and potential for confounding

• Use of highly similar control group external to Group Health

GHRI/UW KPCO

Paul Fishman Arne Beck

Nora Henrikson Debra Ritzwoller

Rebecca Hubbard Nancy Brace

Diane Martin

Rob Reid

Ellen Schartz

Aaron Scrol

Kay Theis

Research Team